Postpartum complications

1. Postpartum complications

2. Following NVD the average hospital stay is 1.4 days (1.7 for first-time mothers; 1.2 for previous mothers) • 2 days for an assisted vaginal delivery & 3.4 days following a caesarean.

3. Haemorrhage • Infection • PE • 6/52 postnatal check

4. A 25 year old female presents to her GP with thick, smelly and bloody discharge two weeks after the delivery of her first child. She was otherwise well and was recovering at home from the uncomplicated birth of her child. On examination, the lady was pyrexial and was tender over the suprapubic region.  1)What sort of PPH is this? 2)What is the likely pathology? 3)What was the GP's course of management?

5. PPH • Minor PPH (500 mls- 1L) / Major > 1L • Primary PPH = >500mls within 24 hours • Secondary PPH = abnormal bleeding 24hours & 6 weeks.

6. Primary PPH • Common cause: 70% uterine atony

7. Secondary PPH • Infection : Endometritis • RPOC

8. PPH = 4 T’s • Tone (uterine tone) 70% • Tissue (retained tissue - placenta) 20 % • Trauma ( Lacerations and uterine rupture) 10% • Thrombin ( coagulation disorders) 1%

9. Management Primary PPH • If haemodynamically unstable  ABC, O2 and IV access. Bimanual compression and uterine massage.

10. Management of 2nd PPH in primary care Investigations: • FBC • Midstream Urine • High vaginal swab • Ultrasound Start broad spectrum abx Co-amoxiclav + metronidazole

11. Infection -Endometritis • Infection of endometrium • Ascending infection from lower genital tract • most important factor the mode of delivery • 1-3 % after NVD, 15-40% after C-section

12. Hx: Fever, abd pain, offensive d/c, dispareunia O/E: Pyrexia, tachycardia, lower abd tenderness, offensive d/c, uterine and adnexal tenderness

13. Ivx: • Blds: FBC,CRP • Microbiology: HVS, endpocervical/chlamydia swab Management: Broad spectrum antibiotic, surgery for RPOC • 90 % resolve after 48-72 hours IV abx

14. 35 years old lady, 17 day postnatal. Breast feeding, sore and warm right breast for the past 48 hours. 1)Diagnosis 2)Management 3)Advice

15. Mastitis • Inflammation or infection of the breast • 1 in 3 mothers will have mastitis Symptoms: • Mastalgia, swelling and erythema (start usually in section near nipple), temperature, flue like symptoms. • Common organism: S.aureus

16. Management Mild mastitis no treatment. Encourage breast feeding Infective mastitis : start antibiotics - Flucloxacillin 500mg qdsfor 14 days If penicillin allergic: - Erythromycin 500 mg qds for 10-14days

17. Advice - Continue to feed from the affected breast - After each feed express any remaining milk from affected breast - Analgesia (paracetamol & Ibuprofen) - Avoid wearing a bra Complications: Breast abscess 1 in 100

18. Infections (other) C-section wound infection • Episiotomy site - Ensure early detection and management

19. More likely to occur 6/52 post delivery. The risk is 1/500 Increase risk of thrombosis if : - Prolonged labour >24 hours - C section - Received a blood transfusion Pulmonary Embolism

20. Symptoms: Dyspnoea/ pleuritic chest pain /cough-haemoptysis/ R HF in severe cases Signs: Tachypnoea/ tachycardia/Hypoxia IF PE suspected, start treatment dose LMWH and admit to hospital

21. Postnatal prophylaxis

22. 6 weeks postnatal check

23. Postnatal check • Should cover: - Physical - Psychological - Social

24. Physical • Mode of delivery • Concerns about own health • Perineum/ C- section scar healing well? • Discharge/ periods • Bowel and bladder • If breast feeding, soreness or engorgement

25. Examination • Abdominal examination ?endometritis/RPOC • Consider checking BP and Hb • Contraception • Pelvic floor exercises

26. Psychological • Any issues around the birth that need discussing • Mood. Can use a postnatal depression screening tool • Any concerns about the baby (should be covered in baby 6 weeks check)

27. Social • Support at home • Sleep • Smoking

28. Summary • PPH 4 T’s • Endometritis • MastitisS.aureusFlucloxacillin or erythromicin for 2/52 • PE ensure high risk women are on LMWH post delivery. • Holistic approach to postnatal check

29. References • Postpartum Haemorrhage, Prevention and Management (Green-top 52) • West Midlands Key Health Data 2006/07 • GP notebook – Mastitis • http://www.fastbleep.com/medical-notes/o-g-and-paeds/16/36/503 (cases) • http://www.patient.co.uk/doctor/Mother's-6-Week-Postnatal-Check.htm • http://www.planapregnancy.co.uk/PP2010/static/GT37ReducingRiskThrombo.pdf • Oxford handbook of obstetrics and gynaecology. 2nd edition

30. ?

31. Cases

32. A 24-year-old woman presents 8 days after giving birth. She complains of a persistent pink vaginal discharge which is 'smelly'. On examination her pulse is 90 / min, temperature 38.2ºC and she has diffuse suprapubic tenderness. On vaginal examination the uterus feels generally tender. Examination of her breasts is unremarkable. Urine dipstick shows blood ++. What is the most appropriate management? A. Arrange urgent ultrasound to exclude retained products + send MSSU + take high vaginal swab B. Send MSSU + take high vaginal swab + start oral co-amoxiclav + metronidazole C. Arrange urgent ultrasound to exclude retained products + send MSSU + start oral co-amoxiclav D. Admit to hospital E. Send MSSU + take high vaginal swab + start oral co-amoxiclav

33. This woman by definition has puerperal pyrexia, likely secondary to endometritis. She needs to be admitted for intravenous antibiotics.

34. Case 2 • Which one of the following statements regarding the lactational amenorrhoea method (LAM) of contraception post-partum is correct? A. 1-2 top up feeds per day are allowed as long as this is in addition to breastfeeding B. Is recommended for mothers with HIV C. Should only be used if women decline long-acting reversible contraceptives D. Is 100% effective if the woman is amenorrhoeic E. The effectiveness decreases after 6 months

35. Lactational amenorrhoea method (LAM) • is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum

36. Case 3 • A 29-year-old woman who is 2 weeks postpartum consults you regarding contraception. She is interested in having an intrauterine device (IUD) inserted and asks when it could be fitted. She had a emergency caesarean section for failure to progress. What is the most appropriate advice to give? A. An IUD can be inserted 4 weeks postpartum B. An IUD can be inserted 12 months postpartum C. An IUD can be inserted today D. An IUD can be inserted 12 weeks postpartum E. An IUD is contraindicated in the long-term

37. Answer A between 48 hours and 4 weeks postpartum (increased risk of perforation)

38. Case 4 • woman rings for advice 18 days post-partum. She is keen to start her progestogen-only pill again. There have been no problems since giving birth and breast feeding is going well. What is the most appropriate advice? A. Contraindicated if breast-feeding B. Start immediately, effective immediately C. Start on day 28, effective after 7 days D. Start on day 28, effective after 2 days E. Can be started after 3 months, effective after 2 days

39. Answer B • Progestogen only pill (POP) • the FSRH advise 'postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.' • after day 21 additional contraception should be used for the first 2 days • a small amount of progestogen enters breast milk but this is not harmful to the infant